Provider Demographics
NPI:1952692790
Name:MILLER, JASON DOUGLAS (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DOUGLAS
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8173 112TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-2304
Mailing Address - Country:US
Mailing Address - Phone:320-249-2602
Mailing Address - Fax:
Practice Address - Street 1:1921 COBORN BOULEVARD
Practice Address - Street 2:
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-251-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN361660000Medicaid